Chest pain is a common clinical symptom, with different clinical manifestations, rapid changes in condition, and wide differences in risk, including not only acute high-risk chest pain such as acute coronary syndrome (ACS) and acute pulmonary embolism, but also moderate and low-risk chest pain such as stable coronary heart disease and chest wall disease.
The treatment time of acute chest pain is highly dependent, and the receiving doctor should quickly assess the risk of acute chest pain, select targeted auxiliary examinations, and move the treatment front as far forward as possible.
Figure 1. Classification and common causes of acute chest pain
Watchmaking 丨 Health World
Figure 2. Common causes in different pain sites
01
What are the characteristics of acute high-risk chest pain?
The diagnosis of high-risk chest pain is mature and convenient, although the disease is menacing, but as long as early intervention can be treated, grasping the characteristics of acute high-risk chest pain can be quickly diagnosed.
1. The onset is urgent and the clinical manifestations are severe
Acute severe chest pain, chest tightness that suddenly begins, accompanied by breathlessness and even a feeling of imminent death;
Severe hypotension or cardiac arrest, if rescue is not timely, may be converted to sudden death
Atypical symptoms: Impaired consciousness or other systemic symptoms predominate, which increases the difficulty of early diagnosis.
2. Some atypical patients may have specific signs suggestive of diagnosis
Aortic dissection is highly suggestive of differences in blood pressure between the left and right or upper and lower limbs;
Severe hypoxemia, rapid heart rate and respiratory rate, jugular venous distension but the patient is able to lie flat, often suggesting acute pulmonary embolism;
New mitral valve systolic murmurs are more likely to suggest acute myocardial infarction;
With severe dyspnea, asymmetrical left and right breath sounds, unilateral thoracic movements, and decreased or absent voice tremor, highly suggestive of tension pneumothorax.
02
These conditions are the most dangerous, how to quickly differentiate the diagnosis?
1. Diagnosis of aortic dissection
Symptoms: tearing pain; pain radiating to the back, hip, or lower extremities; ischemic manifestations in multiple organs.
Signs: increased blood pressure, pronounced differences in blood pressure in both upper extremities, weakened or absent pulse, heart murmur.
Imaging: aortic-enhanced CT is preferred, and transesophageal echocardiography may be considered in patients with contraindications to contrast.
2. Key points for diagnosing pulmonary embolism
Signs and symptoms: dyspnea, rapid breathing, pleurisy chest pain, cough, hemoptysis, venous thrombosis of the lower extremities, signs are often nonspecific;
Adjunctive tests: cardiac charts are often nonspecific, SI.QIII.TIII. is rare, and D-dimer is positive
Adjunctive testing: pulmonary artery CTAs are of high diagnostic value, and echocardiography suggests increased right-sided cardiac stress
3. Pneumothorax
Symptoms: sudden dyspnea, sudden pleurisy-like chest pain, severe respiratory circulation disorders
Signs: mediastinal displacement, decreased breath sounds, hyper-clear or drumming on percussion, and sometimes signs of pleural effusion
Adjunctive examination: chest x-ray presents as a convex arc-shaped shadow of thin lines, called the chest line, and CT shows a very low-density gas shadow in the pleural cavity. With changes in lung tissue atrophy.
4.ACS
In patients with ACS, the site of pain is mostly located behind the sternum, which can radiate to the neck and shoulders, jaw, upper abdomen, or left forearm, and is often squeezed pain, with a feeling of contraction, suffocation, or burning.
Stable angina generally lasts 2 to 10 minutes and can be relieved after 3 to 5 minutes of rest or nitroglycerin. Chest pain with unstable angina usually lasts more than 20 minutes or increases in the frequency of attacks, and chest pain in myocardial infarction lasts >30 minutes.
Figure 3. Typical VS. atypical clinical presentation of ACS
ECG is the most important tool for early rapid identification of ACS, and the first 12/18-lead ECG should be completed within 10 minutes of the first medical contact.
Figure 4. NSTE-ACS and STEMI ECG performance
Figure 5. Key points in the diagnosis and differential diagnosis of common high-risk chest pain
03
Evaluation and rapid diagnosis of acute high-risk chest pain
Chest pain has a wide variety of causes and requires an immediate assessment of the degree of risk for chest pain (see Figure 6). The assessment process of acute high-risk chest pain is different from that of low- and medium-risk chest pain, the former is mainly based on diagnosing the diagnosis as soon as possible and implementing key diagnosis and treatment to relieve the direct threat to life, and the latter mainly excludes high-risk groups to prevent missed diagnosis and excessive medical treatment.
The first doctor often determines the prognosis of high-risk chest pain patients, how to make the first doctor take fewer detours and quickly clarify the diagnosis of high-risk chest pain patients? The key is to train doctors and nurses in the ability to identify patients with high-risk chest pain and then concisely select targeted complementary tests.
Recently, the American Society for the Prevention of Cardiology released a statement on the application of current cardiac CT angiography, and pointed out that coronary CT should be the preferred test for patients with low- to medium-risk and moderate-risk chest pain, whether it is stability or acute onset.
Chest pain with chest pain with any of the following conditions should be immediately admitted to the intensive care unit or rescue room: altered consciousness; low arterial oxygen saturation (
Figure 6. Flowchart of acute chest pain diagnosis and treatment
Resources
1. Emergency Medicine Branch of Chinese Medical Association, Chest Pain Branch of China Healthcare International Exchange Promotion Association. Expert consensus on emergency diagnosis and treatment of acute chest pain. Chinese Journal of Emergency Medicine. 2019; 28(4):413-420.
2. Xiang Dingcheng. Rapid assessment and diagnosis of acute high-risk chest pain. 2021 China Cardiovascular Health Conference.
3. Diagnosis ideas and treatment principles of acute chest pain, see what the latest guidelines say. China Medical Tribune Cycle Today. 2021-04-15
Author: Tian Xinfang
Source: Cardiovascular Frontline of the Health Community